Keisha Williams

30 yo · 5 days postpartum · G1P1 (SVD) · Blood type A+

Allergies

Codeine — severe nausea/vomiting
Adhesive tape — contact dermatitis

Active Problems

Postpartum, 5 days — SVD 02/21, EBL 450 mL
Increased PP bleeding — called nurse line 02/25, advised L&D triage
Transient HTN in labor — 148/92 during pushing, trended to 122/74 at DC
Episiotomy — mediolateral, healing, pain managed
Baby in NICU — jaundice, phototherapy, improving
Emotional distress — NICU separation, tearful
Sickle cell trait (carrier only)
Small uterine fibroid (1.5 cm, monitoring)
GBS+ — treated intrapartum

Medications

Ibuprofen 600 mg Q6h (scheduled → PRN)
Acetaminophen 1000 mg Q8h (alternating)
Docusate 100 mg BID
Prenatal vitamin + DHA daily
Iron supplement 325 mg daily (prophylactic)
Witch hazel pads, Dermoplast spray PRN
DO NOT USE: codeine products

Key Labs

Hgb (discharge): 10.2 g/dL (low-normal PP)
Hgb (admission): 11.8 g/dL
Platelets: 210 K (normal)
BP (labor max): 148/92
BP (discharge): 122/74
Baby bilirubin (48 hrs): 18.2 — phototherapy

Delivery Summary

SVD at 39w6d. Baby boy, 7 lb 12 oz, Apgar 7/9
Epidural. Active labor 10 hrs. 2nd stage 1h 45m
Episiotomy for variable decels during pushing
EBL 450 mL (upper limit normal)
Nuchal cord x1 — reduced, no issues
GBS+, penicillin G IV x2 doses (adequate)

Family History

Significant HTN family hx — mother, father, brother, maternal grandmother
Mother: HTN, obesity, fibroids (hysterectomy)
Father: T2DM, HTN
Twin sister: G1P1, uncomplicated. Asthma
Brother: HTN (dx age 30)

Social

RN (hospital), on 12-week maternity leave
Married. Husband works nights (warehouse)
Twin sister very involved. Mother helps but works FT
High stress — first-time mom, baby in NICU, sleep 3-4 hrs
Edinburgh not yet administered (planned 2-wk visit)

Recent Communications

02/25 — Patient phone call: "Bleeding picked up. Soaked through a pad in about 2 hours and passed a quarter-sized clot. Felt dizzy standing up. Husband at work tonight."

02/25 — On-call NP: Come to L&D triage. If soaking pad/hour or feeling faint — call 911. Don't drive if dizzy. Check temp before coming.

Review Submitted